​

Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, we're highlighting from community to cellular therapy, how AHN is expanding access to trials, CAR T, bispecifics, and virtual consults.

Joining me today is Dr. Prerna Mewawalla. She's an Associate Professor at Drexel University and the Director of Stem Cell Transplant and Cellular Therapy at the AHN Cancer Institute.

Dr. Mewawalla, thank you so much for joining us today, and we're seeing such a rapid evolution in oncology from traditional community care models to highly specialized therapies that we've been, you know, talking so much about like CAR T and bispecific antibodies. Set the stage a little bit for us. What's changed most as you've seen it in how patients are accessing some of this cutting-edge cancer care?

Dr. Prerna Mewawalla: Thank you so much for having me, Melanie. I think things have made so much progress in the field of malignant hematology, that it's wonderful. For example, especially in multiple myeloma, we've seen CAR T move on to earlier lines where we do CAR T in second line. And we've also seen that with bispecifics, where bispecifics are now approved for second line. But I always say this, that therapy is only as good as its access. A lot of times, these treatments like bispecifics are still mainly being done at academic centers all over the country. But at AHN, we have been able to get these into our community sites and our community infusion sites. So, I think it's a great time for malignant hematology and especially myeloma.

Melanie Cole, MS: Well, it's certainly an exciting time, and everything is advancing rapidly. So historically, Doctor, there's been a gap between community practices and academic centers in offering these trials. They've been elusive and a bit of a mystery, and certainly cellular therapy. So as you've seen in your career the biggest barriers, what are those? And are patients being identified earlier now for some of these advanced therapies? How does that change outcomes, and what have you seen in that gap and those barriers?

Dr. Prerna Mewawalla: Yeah, I think things have changed a lot. I can start with talking about the clinical trials. Previously, clinical trials were considered only for patients who had failed everything else, and they were like, "Okay, now we have no other option, and we should consider a clinical trial at this point." But now, the drugs that are being studied in clinical trials are so effective that we ideally would like to have a clinical trial for every patient walking into AHN.

For example, for a frontline myeloma for a patient who's transplant-eligible versus transplant-ineligible, for a patient in the maintenance setting, for the patient in smoldering myeloma, as well as recurrence/relapse setting as well. And I think even the outlook towards clinical trials has changed over time, where patients are more accepting of clinical trials. There's less mistrust. But I do think with clinical trials, unfortunately, they are still restricted a lot to the academic site. And we do see a difference in patients with higher socioeconomic status being able to access it just because of where they live, being able to come to the primary site. So, I think that is something we still need to work on.

Melanie Cole, MS: Well, so along those lines then, what role do you see community oncologists playing in that continuum? Are they co-managing, referring earlier, staying involved throughout, or once they're referred, do they back off?

Dr. Prerna Mewawalla: I think it's so important that a referral is made almost as soon as the diagnosis is made. And things have gotten so much easier now. We have tele-video visits. We have virtual consults. Previously, we are a referral center for patients who live in a three-hour radius. So, it's difficult for patients who are older, don't have enough family support to drive and come all the way to the city.

But virtual visits and tele-video visits have made it possible for patients to access specialized care, even just being at home for a second opinion or even just to guide treatment. And there is so much changing in each of these diseases, whether it's myeloma, lymphoma, or leukemias. I almost think at the time of a diagnosis, it's very important to at least get maybe a tele-video visit with the patient and just to help guide care. And that care can be given closer to home with the community oncologist at the infusion site close to them. But I think it's very important to actually refer right away and very early.

Melanie Cole, MS: Yes. Thank you for telling us about that importance of early referral. So, give us a bit of an overview of the hematology program at AHN about your network structure and the breadth of services, including malignant hematology, transplant, cellular therapy, the things we're touching on today.

Dr. Prerna Mewawalla: Absolutely. At AHN, we've built a highly integrated hematology and cellular therapy program that combines specialized expertise with broad regional access. We have expertise in malignant hematology, stem cell transplant, cellular therapy, TILs, apheresis, as well as classical hematology.

One thing that's really strengthened our program is increasing disease-specific specialization within malignant hematology. So, we have physicians who do only plasma cell disorders, which are like myeloma or amyloidosis. We have physicians who do only lymphoma versus physicians who are only focused in leukemia, and that gives patients access to highly specialized care when you see that.

While our malignant hematology division is primarily based at one hospital, we are able to deliver many of our treatments through the AHN network at multiple infusion centers across the region. And if I'm not wrong, there are over 20 infusion centers we can give these treatments at, which patients really like, where they're like, "This infusion center is really close to me. I don't have to drive two hours to get this." And we've been able to do that. We really cover the full spectrum of heme care, right from diagnosis to upfront treatment, all the way through transplant, relapse management, as well as long-term survivorship care.

On the transplant side of things, we have both auto transplants as well as allogeneic transplants. For lymphomas and myelomas. We also have CAR T available. For solid oncology, we have TIL therapy that we can do here. And we also have newer therapies like bispecific antibodies for lymphoma and myeloma, which we are able to do.

We also have a very active apheresis program where we are able to do plasma exchange for other specialties as well. Like, we also have neurology and nephrology where some of their diseases require plasma exchange, and we are able to do that at our site as well. And in addition to supporting other services, we also collect stem cells for unrelated donors through the National Marrow Donor Program, which is an important part of expanding access for transplant and cellular therapies more broadly. In addition, we have multiple clinical trials across malignant hematology as well as cellular therapy, giving patients access to newer and very effective treatments early on.

And I think one of the very important things that we are doing is we were talking about getting access to these treatments in the community. And a very good example of that is bispecific antibodies for multiple myeloma. Most of the time for bispecific antibodies with myeloma, the initial ramp-up due to risk of cytokine release syndrome and neurotoxicity, a lot of times is done at the academic site. But because of creating protocols and workflows and using the right prophylaxis, we have been able to get the ramp-up of these bispecific antibodies into the community site, where if patients live within an hour of our academic site, they are able to get this ramp-up dosing even at their community site. So previously, where patients would be like, "We don't want to travel for this treatment," and they would actually not get this treatment, they're now able to get it close to home, and we've been able to do that at AHN.

Melanie Cole, MS: Wow. Isn't that amazing? So, you're really seeing that movement toward delivering these exciting therapies closer to where patients live. And how are you ensuring, Doctor, that diverse patient populations are being reached as well?

Dr. Prerna Mewawalla: Yes. And that's exactly how we are doing that because a lot of times that's where we see the gap where patients with lower socioeconomic status, they're not able to travel, they don't have the means for transportation to come all the way here. So by doing tele-video visits, by doing virtual visits with these patients and giving these treatments close to them at any of our infusion sites, it has really changed access.

And I feel like I see progress almost every few months. Things we couldn't do last year in the community, this year we can. And we are constantly striving and working towards moving more and more into the community to get patients access to these very, very effective treatments.

Melanie Cole, MS: Yes, I think that's so important. Now, you've mentioned bispecifics a few times, and they're really generating a lot of excitement in the medical community. How are they fitting into the treatment landscape, Doctor, alongside CAR T? How are clinicians deciding sequencing CAR T versus bispecifics? How are you putting this all together?

Dr. Prerna Mewawalla: Yes, absolutely. And that's especially a very good discussion for myeloma. And I think that's why it's very important that these patients are referred to us, to the transplant site so we can have a discussion with them. And it's not one-size-fits-all. I generally have a discussion with the patient because CAR T is a very effective treatment in second line, and it is one and done. You give CAR T. And if it works and you're in remission, you do not need to be on maintenance chemotherapy, like we generally do for myeloma. So, that's the benefit of CAR T.

But in the same breath, it also has side effects of ICANS and CRS, and also it can cause long-term neurotoxicity as well. So, being very careful about selecting these patients, selecting high-risk patients for earlier CAR T is important, and also taking into account all the comorbidities that are there.

On the other hand, when it comes to bispecifics, they are off-the-shelf. They are readily available. People don't have to travel to the academic site. They can get it closer to home. Also very effective, but they need to be on it indefinitely. So, that's the difference there.

The other place where bispecifics are used more is if somebody has rapidly-progressing disease. CAR T does have a lag due to the manufacturing time. So if someone does have rapidly progressing disease and you need to control the disease quickly, then bispecifics are available more easily to be able to do it right away. Even in patients which were extremely hard to treat previously with extramedullary disease, there has been now data in using combination bispecifics, using combination of teclistamab and talquetamab. That's a very difficult-to-treat population, and we are able to do that and have good response rates with those patients as well.

Melanie Cole, MS: Wow, really such an exciting time. Now, you mentioned virtual access and the importance of telemedicine visits to streamline those second opinion consultations and for oncology consults. So, tell us a little bit about that virtual access, how that works, and how really patients are embracing this and physicians because it helps to keep that continuum of care.

Dr. Prerna Mewawalla: So, the Cancer Institute has come up with something called as the HopeLine, where patients can call just one number and make sure they get an appointment timely. In case there is a backlog of appointments, it's automatically escalated to the physician. And if there is a patient which needs to be seen, we'll see them right away in the next few days as needed.

And when it comes to virtual access, it's done through my chart, through Epic, where it's a video visit, but it's HIPAA-compliant, where we can talk to the patient. We can see the patient, so we can also see what they're looking like. We have access to all their labs. So, it's almost like we are able to do everything on a virtual visit, which has been very, very helpful for these patients.

Melanie Cole, MS: Yes. You've given us so much great information. And now, we talked about early referral before. I'd like you to speak to other clinicians, practical triggers for early referral in myeloma and other hematologic malignancies. What would you like some of those red flags to be? What would you like other clinicians and community physicians to know about the reasons and the red flags for early referral?

Dr. Prerna Mewawalla: I think a patient with any malignant hematology diagnosis should be referred at diagnosis. And like I said, it's not only to guide treatment initially. We also have clinical trials which are upfront clinical trials. So if we miss that window, you could also miss access to a very good clinical trial which we have available frontline.

So, I think that every patient with a malignant heme diagnosis should be referred to us at diagnosis, even just for a virtual consult. And we can be involved as needed as things go along, maybe once at diagnosis. And if they don't respond at relapse or for second-line and third-line treatments, I think it's so important that these patients are actually referred at diagnosis because we have trials for frontline myeloma here.

And if they aren't referred in time, we completely miss those patients. Our oncologists at HN have been absolutely wonderful. And we generally give our cell phone to community oncologists. We would like them to contact us as needed, and we will get a patient in to be seen right away.

Melanie Cole, MS: This is such great information. As we wrap up, Doctor, what would you like clinicians listening today to start doing differently tomorrow to improve that access for their patients? As we said before, it used to be that clinical trials and access to these highly advanced therapies were so elusive, but not anymore.

And from what you're telling us, AHN is making it much more broad for the communities. If you were to look ahead, what does an ideal fully integrated oncology care model look like? And what's the one message you want the community oncologists to walk away with regarding that access to these therapies?

Dr. Prerna Mewawalla: Absolutely. And like I said, therapy is only as good as its access. So, the biggest takeaway I want to say is refer these patients very, very early, and we are constantly coming up with models to get more and more and more treatments out in the community. And we will work with local oncologists to make sure that patients get all the treatments that they need. Just text us, Epic chat us, we are always here, and we'll get these patients seen right away.

Melanie Cole, MS: Thank you so much, Doctor, for joining us today and sharing your incredible expertise. And to learn more or to refer your patient, please call 844-MD-REFER, or you can visit findcare.ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.